Improving Refractive Results of Cataract Surgery Through Audit

The main challenge of modern cataract surgery is meeting patient expectations. Most often, the refractive outcome determines the success of surgery and the level of satisfaction our patients experience. The surgeon’s objectives include spherical targeting, astigmatism correction, and management of presbyopia. Advances in biometric techniques, newer formulas for intraocular power calculation, meticulous surgical planning and execution, and new IOL designs including toric IOLs and the use of secondary enhancement IOLs (ie, multicomponent or piggyback) have helped surgeons to reproducibly achieve predictable refractive results.

However, variations in outcomes still occur. To improve the results of cataract surgery, we must understand the causes of these variations, monitor their effects, and make the necessary adjustments. The audit is an invaluable tool in assessing clinical performance and should adhere to generally accepted standards set by governing bodies. It should be an independent evaluation of data that includes both quantitative and qualitative analysis.

EARLY EXAMPLES OF AUDIT
Florence Nightingale, OM, RRC, conducted one of the first clinical audits during the Crimean War (1853–1855). Ms. Nightingale studied the relationship between the unsanitary conditions of the Barrack Hospital at Scutari, Turkey, and the high mortality rate among the injured and ill soldiers. Her team of nurses introduced strict sanitary routines and applied high standards of hygiene in the hospital and to the equipment. As a result of Nightingale’s analysis and her nurses’ work, the mortality rate fell from 40% to 2%.¹

Ernest Amory Codman, MD, is also known for his work in the early days of clinical audit. Dr. Codman was the first American to follow the progress of surgical patients through their recoveries in a systematic manner using the end result concept. Cards were used to track the basic demographic data of every patient treated, including diagnosis, treatment, and outcome. Patients were followed for at least 1 year with the goal of identifying surgeon errors. Dr. Codman also believed that this information should be made public so that patients could be informed when choosing physicians and hospitals.

Ms. Nightingale’s epidemiologic audit and Dr. Codman’s clinical approach used different methodologies that each produced significant improvements in patient care.

PRESENT-DAY MODELS
Ophthalmology enjoys a plethora of technologies that allow individual surgeons or departments to audit cataract and refractive surgery results, including electronic medical records, data management systems, and computer software. Clinical audit has been incorporated into many European health care systems. For example, clinical audit was formally introduced into the United Kingdom’s National Health Service in 1993. Sweden, Denmark, and the Netherlands have since adopted national cataract audit systems. The level of sophistication of and surgeon participation in these audit systems vary significantly, but all aim to provide information on quality of care, safety, data for benchmarking, analysis of results for improvement in outcomes, and information for setting guidelines. In some countries, reimbursement for eye care service requires involvement in such audits.

THE EUREQUO PROJECT
The European Registry of Quality Outcomes of Cataract and Refractive Surgery (EUREQUO) aims to provide a system for 16 European countries (Austria, Belgium, Denmark, Finland, Germany, Greece, Hungary, Ireland, Italy, Netherlands, Norway, Slovakia, Spain, Sweden, Turkey, and the United Kingdom) to collect and register data on cataract and refractive surgery and to analyze the data and audit the outcomes, either on an individual basis or for a collective unit. This system allows surgeons to monitor their clinical outcomes and compare their results with those of other surgeons or against an organizational standard. This should lead to evidence-based exchange of best practices among surgeons or institutions, improvement in patient care and safety, the development of European guidelines for cataract and refractive surgery, and benchmarking.

The EUREQUO project commenced in 2008 after the European Society of Cataract and Refractive Surgeons (ESCRS) secured funding for a 3-year program from the European Union under the Executive Agency for Health and Consumers. The first phase of the project (2008–2009) assessed the software requirements of various national cataract and refractive surgery datasets (national registries) and developed an appropriate online system for EUREQUO. The second phase (2009–2010) tested and refined the Webbased system in selected participating countries. The third phase (2010–2011) will roll out the project to the rest of the participating European countries.

Mats Lundström, MD, PhD, of EyeNet Sweden, Blekinge Hospital, Karlskrona, Sweden, is the clinical advisor for the EUREQUO project. The ESCRS is the lead partner for the project and has committed financial support for an additional 3 years, starting at the end of 2011 (personal communication). Other partners include national ophthalmology societies and cataract and refractive societies of the participating countries. The ESCRS has vast experience in supporting independent quality registry systems, specifically the European Cataract Outcome Study (ECOS) and the Refractive Surgery Outcomes Information System (RSOIS).

By the end of 2011, all participating surgeons and institutions will be able to register outcomes on EUREQUO. Although the ESCRS is responsible for coordinating the project, the national registry manager in each participating country will recruit and implement the EUREQUO initiative. Registry managers are responsible for soliciting the support of relevant national health agencies, ophthalmic societies, medical organizations, cataract clinics, and surgeons to assist with the smooth transfer and integration of datasets and institutional and personal data into the EUREQUO system. Currently, a few hundred thousand cataract and refractive datasets have been promised for transfer to the EUREQUO network. It has been projected that, by the end of 2011, close to 1 million datasets will be entered into the system (personal communication).

IMPROVING RESULTS
The parameters that determine the success of cataract surgery change regularly due to technological advances. Cataract surgery is no longer a simple procedure for removing a physical barrier to vision; the procedure is increasingly used to achieve a desired refractive outcome, which is a product of three main objectives that can be monitored by auditing data relating to the following:

1. Spherical targeting. This evaluates the accuracy of biometry techniques and the appropriateness of the formula(s) used in IOL power calculation in relation to the axial length of the eye and the surgeon’s A-constants;

2. Correction of astigmatism or maintaining astigmatic neutrality. Such correction is an important indicator of the quality of the surgical technique with respect to the site and size of the incision and its construction, the use of additional incisions, and the choice of IOL (standard or toric);

3. Provision of near vision. Near vision can be achieved with spectacles, monovision, or presbyopic IOLs.

Currently, the EUREQUO online registry for cataract surgery contains five data fields: patient, preoperative, intraoperative, postoperative (1–6 days), and postoperative (7–60 days). The information required in these fields should provide both quantitative and qualitative analysis of the refractive results of cataract surgery, but further refinements may be required to accommodate future advances in technology.

CONCLUSION
The EUREQUO project is a powerful audit system that will allow cataract surgeons to monitor their results and compare them against a Europe-wide benchmark with the promise of improving the refractive results of cataract surgery. For additional information on EUREQUO or how to participate, visit www.eurequo.org or contact Lucia Brocato (lucia.brocato@ escrs.org), the EUREQUO Project Manager.

Tayo Akingbehin, MD, FRCS, FRCOphth, is a Consultant Ophthalmic Surgeon and Refractive Surgeon and Medical Director of iSight Clinics in the United Kingdom. Dr. Akingbehin was a member of the ESCRS EUREQUO committee in 2009–2010. He states that he has no financial interest in the products or companies mentioned. Dr. Akingbehin may be reached at tel: +44 1704 563279; e-mail: tayo@isightClinics.com.

1. 1.Grier MR.Florence Nightingale and statistics. Res Nurse Health.1978;1:91-109.

TAKE-HOME MESSAGE
• An audit should should be an independent evaluation of data.
• EUREQUO aims to provide a system for registered users in 16 European countries to collect, register, and analyze data on cataract and refractive surgery.